AUTHORIZATION OF RELEASE OF INFORMATION

Jupiter Concierge Family Practice
David C. Rosenberg, MD
2141 Alternate A1A South
Suite 200
Jupiter, FL 33477
(561) 743-0005
(561) 743-7623 Fax
AUTHORIZATION OF RELEASE OF INFORMATION
I hearby authorize*
Name of Physician / Facility where your records are currently
to release any and all clinical records, including medical, psychiatric, alcohol and any drug abuse records, HIV testing and results to:

Jupiter Concierge Family Practice
David C. Rosenberg, MD
2141 Alternate A1A South, Suite 200
Jupiter, FL 33477
PATIENT’S FULL NAME:*
DATE OF BIRTH:*

MonthDayYear
Date
SOCIAL SECURITY*
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
EMAIL ADDRESS*
example@example.com
PATIENT'S SIGNATURE:*

Clear
Should be Empty: